Public Consulting Group

Medicaid Registered Nurse - DMDD 1325

Job Locations US-NY-Albany | US-NY
Posted Date 3 weeks ago(3/13/2023 11:35 AM)
Job ID
2023-9233
# of Openings
1
Category
Customer Service/Support
Type
Regular Full-Time
Practice Area
Staffing Solutions Organization

Overview

Medicaid Registered Nurse – Medical Review in Menands, NY

Item 1325

 

Summary:

The Bureau of Medical Review in the Division of Dental and Medical Directors is seeking a Registered Nurse (RN) to perform reviews of prior approvals and pended claims. The Bureau of Medical Review is responsible for prior approval and post payment review of medical equipment/supplies, private duty nursing, and physician services.  The Bureau is responsible for policy development, fraud and abuse monitoring for these services. 

Responsibilities

Duties: 

 

  • Performing pre-payment review functions in the Bureau of Medical Review within the Prior Approval and Pended Claims Units:
  • Prior Approval – uses electronic prior approval and reference file systems to review prior approval requests for durable medical equipment, private duty nursing and physician services and determine if the service falls within the scope of coverage of the Medicaid program and if the service is appropriate for the individual’s medical needs.
  • Medical Pended Claims - uses the claims processing system and other electronic references to perform pre-payment, post-service adjudication of claims that pend for medical review.
  • Provide clinical expertise to evaluating new technologies that are being considered for inclusion in the Medicaid Fee Schedule

 

Qualifications

 

Qualifications:

 

  • Bachelor’s Degree        
  • Must be currently licensed as registered professional nurse in NYS
  • 4 years post licensure professional nursing experience
  • At least two years which must have been in a licensed healthcare facility.  School nursing or medical office experience does not apply
  • Experience in prior approval of medical supplies/equipment or experience in examination of medical records, documentation, proposed treatment plans for medical necessity.
  • Experience with national standards for procedure and diagnosis coding is preferred.

   

*Employees must follow established work schedules. The usual work schedule is 40 hours per week, Monday through Friday. Normal work hours are 8:00 a.m. to 4:30 p.m. unless otherwise specified by the supervisor, this includes a half hour unpaid lunch break. Total work hours must equal 37.5 hours per week.

 
 
 
 
 

Compensation

Compensation for roles at Staffing Solutions Organization LLC (SSO) varies depending on a wide array of factors including, but not limited to, the specific office location, role, skill set, and level of experience. As required by applicable law, SSO provides the following reasonable range of compensation for this role: 70K to 80K. In addition, SSO provides a range of benefits for this role.

EEO Statement

Public Consulting Group is an Equal Opportunity Employer dedicated to celebrating diversity and intentionally creating a culture of inclusion. We believe that we work best when our employees feel empowered and accepted, and that starts by honoring each of our unique life experiences. At PCG, all aspects of employment regarding recruitment, hiring, training, promotion, compensation, benefits, transfers, layoffs, return from layoff, company-sponsored training, education, and social and recreational programs are based on merit, business needs, job requirements, and individual qualifications. We do not discriminate on the basis of race, color, religion or belief, national, social, or ethnic origin, sex, gender identity and/or expression, age, physical, mental, or sensory disability, sexual orientation, marital, civil union, or domestic partnership status, past or present military service, citizenship status, family medical history or genetic information, family or parental status, or any other status protected under federal, state, or local law. PCG will not tolerate discrimination or harassment based on any of these characteristics. PCG believes in health, equality, and prosperity for everyone so we can succeed in changing the ways the public sector, including health, education, technology and human services industries, work.

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